Gout

Background

Gout is characterised by the deposition of monosodium urate crystals in joints and soft tissues and usually presents with intermittent painful attacks followed by long periods of remission.

Clinical features which strongly predict a diagnosis of gout

• First MTP joint involvement
• Rapid onset (6-12 hours) of severe joint pain with swelling, tenderness and overlying erythema
• Self-limiting with complete resolution
• Tophi (proven or suspected)
• [Urate crystals seen in joint aspirate].

Note: serum urate may be normal during an acute attack.

Acute gout management

Treat as early as possible. Keep affected joints rested, elevated and cool.

Medical management:

• 1^st line: NSAIDs (Ibuprofen or Naproxen) plus PPI continued for 48 hrs after attack has resolved.
• 2^nd line: Colchicine 500 micrograms 2-4 times per day, until symptoms are relieved. Can be used in patients on warfarin and in patients with heart failure. Note can cause profuse diarrhoea and toxicity at higher doses.
• 3^rd line: Corticosteroids
  • Oral : prednisolone 20 - 40 mg daily for 5 days
  • Intramuscular injection: Depomedrone 80 - 120 mg or Kenalog 80 mg
  • Intra-articular injection for gouty monoarthritis: Depomedrone 10 - 80 mg or Kenalog 10 - 40mg.

Do not interrupt urate lowering therapy during an acute flare of gout

Following on from an acute attack

1. Educate patients about the disease and where appropriate modify risk factors such as
   • Drugs eg diuretics, ACE inhibitors, ARBs (not losartan), ciclosporin, high dose aspirin. If on diuretics for BP control rather than heart failure, consider changing drug
   • Excessive consumption of red meat or seafood
   • Fructose-sweetened drinks and alcohol
2. Treat underlying cardiovascular risk factors (obesity, hypertension, lipids diabetes); there is an emerging link between abnormal serum urate levels and CV disease
3. Consider urate-lowering therapy if the patient has:
   • Recurrent attacks (>2 attacks in 12 months)
   • Polyarticular flare at presentation
   • Tophi
   • Joint damage
   • Renal impairment (eGFR <60 ml/min)
   • History of renal stones
   • Gout starting at a young age.

See chronic management of gout below for further details.

Chronic gout management

Ensure serum urate levels are obtained during the 4 weeks following an acute attack. DO NOT START URATE LOWERING THERAPY DURING AN ACUTE FLARE OF GOUT BUT DO NOT INTERRUPT TREATMENT DURING AN ACUTE FLARE EITHER. Ensure at least 1-2 weeks have passed before starting OR increasing urate lowering medication.

• 1^st line urate lowering treatment: Allopurinol
  • Please see table below for starting dose – Adherence to these doses will reduce risk of rare but potentially fatal reaction of allopurinol hypersensitivity syndrome (AHS)
  • Increase dose, same as starting dose, only every 4 weeks.
  • Monitor serum urate levels monthly and increase dose if required until serum urate is<360 μmol/l or maximum tolerated dose is reached (maximum dose 900mg daily)
  • Prescribing guidance:
    • Allopurinol potentiates the anticoagulant effect of warfarin.
    • Allopurinol inhibits azathioprine metabolism, leading to build up of toxic metabolites and bone marrow suppression. Please contact for advice.
• 2^nd line urate lowering treatment: Febuxostat
• If allopurinol is contraindicated, not tolerated or there is inefficacy despite titration to maximum tolerated dose.IT IS NOT RECOMMENDED FOR PATIENTS WHOSE eGFR IS LESS THAN 30
• Start at 80 mg/day
• Increase to 120 mg/day if target serum urate is not reached after 4 weeks
• Prescribing guidance:
  • Caution is required if prescribing febuxostat in patients with pre-existing major cardiovascular disease, particularly, in those with evidence of high urate crystal and tophi burden or those initiating urate-lowering therapy.
  • Avoid prescribing to patients taking azathioprine or mercaptopurine
  • Stop IMMEDIATELY if hypersensitivity occurs
• Always co-prescribe prophylaxis for up to 6 months:
• Colchicine (500 micrograms twice daily)
  or
• NSAID plus PPI to prevent an acute gout flare
  or
• Once a month intramuscular depomedrone injection (80mg if patient weight <60kg, 120mg if weight >60kg)
• Patients with chronic tophaceous gout should have a target serum urate level of 200 – 250 μmol/L as it takes years of sustained hypouricaemia to dissolve tophi
• Ensure compliance in patients whose serum urate is not sufficiently lowered despite high doses of urate lowering therapy
• Once serum urate target is achieved, annual serum urate measurements are sufficient.

Long term management – Long term urate lowering therapy is appropriate (40% relapse at 5 years when treatment is stopped) but deprescribing could be considered where modifiable risk factors are addressed and clinical ‘cure’ achieved.

Resources for patients

Versus Arthritis booklet for gout